Trauma 101 – What Parents Need to Know

Parents of children with so-called ADHD, Bipolar Disorder, learning disabilities anxiety disorders, even Pervasive Developmental Disorder need to know what trauma is for children and that the effects of trauma can be healed. Most times I interview parents they tell me their child has never experienced a trauma. Yet when I ask more specific questions about accidents, injuries, falls, surgeries, hospitalizations, medical or dental procedures, as well as in utero and delivery experiences, their face turns white.

Their memories are jogged. They suddenly recall the event. The one everyone told them was nothing, that their child would outgrow because, after all, children are resilient. Worse, they are told that their child will never remember the event. “They’re so young,” they say, “They’re just babies. They don’t even speak.”

Parents know, however, that after the event, however seemingly benign or routine, their child was never the same, and the neuroscience supports them. Both the central and autonomic nervous system can be changed in very specific ways after a traumatic event. But what is trauma for a child? What exactly can be considered traumatic for them? This is what too many parents, educators, mental health providers, even medical doctors do not know.

To become traumatized, a child must have had an experience or multiple experiences of terror, an encounter with the possibility of death. It is the body experiencing a threat to its own survival. It does not matter whether the event that threatened or terrified the child was real or not. It does not matter whether or not someone else would experience the same event as threatening or terrifying. Trauma for children is any event – real or perceived – that is terrifying or threatening to them.

Not everyone who experiences a traumatic event becomes traumatized. Depending upon how many resources are available at the time of the event, as well as whether or not previous traumas have been experienced, some do well in the face of danger and carry on without any noticeable sign of what they went through. Others, even if at first they seem all right, later develop signs and symptoms that something is not the same.

Traumatic effects are not always noticeable immediately following the event(s) that caused them. An early fall that causes shock or injury may produce no obvious problems at first. It may not be until years later, until another frightening event occurs that the effects of a previous incident begin to show. Dr. Peter Levine, a leading expert on the healing of trauma, wrote in his book, “Waking the Tiger: Healing Trauma,” that “symptoms can remain dormant, accumulating over years or even decades. Then, during a stressful period, or as a result of another incident, they can show up without warning.”

As weeks, months, and years pass, children who seemed “just fine” immediately after a crisis may begin to struggle with their sleeping patterns, eating patterns, level of concentration, and/or ability to focus and be in the here and now. Some may become more agitated, more easily upset, and more difficult to soothe. They may report a sore tummy, headaches, or pain in their limbs. Others may report nightmares, difficulty remembering, and “jitteriness” inside that will not go away. Students who experience trauma may develop a sense that something bad is going to happen and they need to be ready for it.

Trauma is Real or Perceived

While there are some events that are obviously traumatic, there are many others we simply assume are harmless when they are not. It is the perception of threat that is the critical factor. For instance, an extremely loud sound like a car backfiring is a seemingly benign or harmless event, not obviously traumatic. To someone who has been traumatized by gun fire on the streets of their neighborhood, however, such a sound may conjure up previously terrifying or life-threatening situations. It is how the event(s) is perceived and experienced by the individual that matters.

Events that are more obviously traumatic include:

– war
– rape
– torture
– severe childhood abuse and/or molestation
– witnessing or experiencing domestic violence
– large catastrophic events, such as Hurricane Katrina
– community violence, such as witnessing or experiencing an act of violence as in the case of Columbine and the many more recent school terror situations
– near death experiences, such as almost drowning (even in the bathtub) or suffocating to death

Less obviously traumatic events include:

– chronic disease or serious illness
– physical neglect and abandonment
– fetal distress (high levels of stress during pregnancy and/or birth)
– birth complications
– surgery and other invasive medical or dental procedures, especially when they involve restraint or isolation
– general anesthesia
– car accidents, major or minor
– falls, injuries or other accidents (even on bicycles)
– being threatened, attacked or bitten by an animal
– sudden death or loss of a loved one
– prolonged immobilization from casting or splinting
– high fevers, accidental poisoning, exposure to extremes in temperature
– being lost, i.e. at the mall or in a strange neighborhood
– bullying
– acts of racism and prejudice

Remember, even if one or more of these events occur during the earliest years of life, they have the potential to traumatize. No matter how young, even preverbal children experience trauma and remember terror in the very cells of their body. Infants and toddlers may be too young to verbalize and cognitively process traumatic experiences but they are not too young to be changed by them. (For more information, please read “Why Students Underachieve: What Educators and Parents Can Do about It,” pages 47, 48.)

Most importantly, know that trauma can be healed, and when it is, all so-called symptoms go away. These children do not have lifelong disorders that can only be managed by medication and therapy.

Fatal Complications During Bronchoscopic Dilation In Two Children With Severe Subglottic Stenosis

Introduction

Postintubation airway stenosis is not an uncommon problem with pediatrics in Iran. Over the last 12 years, there have been 890 patients (new cases) with postintubation airway stenosis referred to our general thoracic surgical unit situated at Dr. Masih Daneshvari hospital, Tehran, Iran. In total some 10% have been children less than 10 years of age. Furthermore, almost all of the affected children suffered from subglottic stenosis.

Postintubation subglottic stenosis in pediatrics is a threat to life which often needs emergent intervention to relieve airway obstruction. Depending on the degree of subglottic damage, there are a variety of techniques to control the airway of pediatric laryngeal strictures (1,2,3,4). However, these airway managements are potentially difficult, and not without risk to the patients. Moreover, the safest intervention for providing a stable airway in children whose situation is emergent has not been made clear yet.

In this report we present two children with severe postintubation subglottic stenosis. In both patients, failures of emergency rigid bronchoscopic dilation lead to adverse events.

Case reports Patient 1

A boy, 6 years of age, weighing 21 kg having postintubation subglottic stenosis with a significant stridor and mild hypoxemia, was directly admitted to the operating room for emergent rigid bronchoscopic dilation under general anesthesia.

Under deep mask inhalational anesthesia with halothane in O2, laryngoscopic examination revealed marked stenosis immediately below the subglottic larynx as well as unilateral vocal cord paralysis. The thoracic surgeon then successfully passed a No 2.5 ventilating rigid bronchoscope through the stricture. The next attempted insertion of the No. 3 rigid bronchoscope was unsuccessful. Subsequent multiple failed attempts at insertion of No. 2.5 resulted in complete airway obstruction. Consequently, extensive subcutaneous emphysema developed. As well, the anesthesiologist was not able to ventilate the patient via the face mask. It was then noted that due to considerable rupturing of subglottic lumen, the bronchoscope was frequently entering into the neck. Hence, emergency tracheotomy was initiated. However, during prolonged difficult tracheotomy procedure (about 30 minutes) asystolic cardiac arrest occurred.

On insertion of a 5 mm cuffed tracheotomy tube distal to laryngeal tearing, adequate ventilation was reestablished and cardiovascular function was stabilized soon after. Due to prolonged cardiac arrest and uncertain neurological state of the patient, the surgeon decided not to repair laryngeal tearing through an open surgical approach. The child was transferred to intensive care unit (ICU) with a Glasgow Coma Scale (GCS) of 6/15 points and mechanical ventilation of the lungs was provided. In the first 3 hours, the child remained hemodynamically stable with no need for inotropes. Thereafter due to accidental displacement of the tracheotomy tube, massive subcutaneous emphysema and severe hypoxemia developed. Untimely reestablishment of the airway resulted in his death. Patient 2 A boy, aged 10, weighing 35 kg, a case of postintubation uncorrectable severe stricture just beneath the glottis presented with severe stridor and mild hypoxemia as a consequence of removal of his temporary tracheotomy tube hours earlier. He was brought emergently into the operating room for reinsertion of tracheotomy tube under general anesthesia.

Under a sufficient level of inhalation anesthesia with sevoflurane in O2, with the patient breathing spontaneously via face mask, thoracic surgeon failed to insert even the smallest pediatric tracheostomy tube. As well, opening of the obstructed tracheotomy with smallest Hegar dilator and the No. 2.5 ventilating rigid bronchoscope were also failed, while the child still was well oxygenated. Thereafter, repeated attempts to pass the No. 2.5 rigid bronchoscope through the subglottic narrowing worsened laryngeal obstruction. As a consequence, progressive hypoxemia developed and manual ventilation became impossible. Subsequent failed attempts to pass No 2.5 rigid bronchoscope and tracheal tubes either through the tracheotomy or the mouth resulted in extensive generalized subcutaneous emphysema. By now the surgeon found that the instruments mostly were inadvertently entering into the soft tissues of the neck (fig 1). While airway maintenance was still being tried through rigid bronchoscopy, asystolic cardiac arrest occurred. When the trachea was intubated by a No.2.5 rigid bronchoscope via the mouth, patient ventilation was reestablished. However, blood pressure was restored with the IV infusion of dopamine. With much attempts while bronchoscope in the trachea and under nasogastric tube guidance, a 4 mm ID uncuffed tracheotomy tube was placed and ventilation was established through it.

In the ICU, he had a GCS of 3/15 points and supported with ventilator. Some 6 hours later, he developed extensive subcutaneous emphysema with severe hypoxemia because of dislodgment of the tracheostomy tube. Unsuccessful reestablishment of the airway lead to patient’s death.

Discussion:

Postintubation subglottic stenosis in children indicates a main therapeutic challenge. Despite a variety of management options, yet it is not evident that in emergencies which intervention, rigid bronchoscopic dilation or tracheotomy has the priority for providing a stable airway in children with severe postintubation subglottic stenosis.

Rigid bronchoscopic dilation of stenotic lesions is known as a lifesaving procedure in adults with critical postintubation central airway obstruction (5,6,7). Though, it may seldom have a role in the management of pediatric subglottic stenosis (1). Practically, the combination of the small orifices of pediatric ventilating bronchoscopes, a significantly narrowed subglottic orifice and the small size of pediatric airway do not allow a good visualization to verify atraumatically passage of bronchoschope through the stricture. Particularly, when too many forces applied, the tip of bronchoscope may inadvertently perforate subglottic region or introduce into the soft tissue of the neck. This in turn further impairs the visualization and therefore, makes the more likely for the frequent operator’s error before the exact diagnosis is made. The detrimental complications can even take place in the hands of expert bronchoscopist.

In the case of proximal upper airway tumors with significant obstruction, immediate tracheotomy under local anesthesia may be the best method to handle the airway (7). Additionally, it is often the most appropriate primary step in a child further than the neonatal age of subglottic stenosis (3). However, it is not commonly recommended to manage acute postintubation tracheal obstruction (8). In our opinion, in an emergent state, unhurried tracheotomy is the safest procedure for obtaining a stable airway in children with severe postintubation subglottic stenosis. In our experience, when obstruction is severe, the successful passage of the first bronchoscope does not guaranty the safe passage of the next one. This can be greatly anticipated if the rigid bronchoscope must be forced via the stenosis. If it is decided to pass a rigid bronchoscope through the stenosis, we suggest only one gentle attempt. Once the airway is established with the first attempted rigid bronchoscope, it is safer to use it as a tracheal tube until placing a tracheotomy. Accordingly, in the first case, because of severity of stenosis, tracheotomy should have been followed while the patient still maintained adequate spontaneous ventilation. Also, the emergency time consuming tracheotomy performed in such uncontrolled situation could not provide a stable airway. Likewise, in the second child, we believe obstructed tracheotomy should have been surgically opened when the situation was under control. In both patients, persistent attempts at opening the severely narrowed subglottic airway by rigid bronchoscopy progressed to a “can’t ventilate/ can’t intubate” situation.

On the other hand, the tracheotomy is best to perform when these pediatric patients are anesthetized and breathing spontaneously. In our common observation, these children are restless, panicked and refuse to be placed supine. By putting them supine and also attempts at awake intubation they would be more agitated which may worsen the airway obstruction. (7). Such as our both patients, we often start an inhalational induction while the children are sited and supported by the anesthesia team, when they lose consciousness, we place them in the operating room table.

Considering our cases, although the physicians who managed the first child were of much more experienced than those in the second one, the step by step communication was inadequate in both cases. This factor probably had a strong influence on not being capable of making well-timed therapeutic decisions. Conclusions Timely and unhurried tracheotomy under inhalational anesthesia should be seriously considered for safely controlling the airway of children with life-threatening subglottic stenosis. Whereas, rigid bronchoscopic dilation is associated with a great risk of severe laryngeal trauma and loss of airway control. It seems spontaneous ventilation anesthesia allows more time to establish a lifesaving airway in difficult conditions.

References:

1. Rutter MJ, Yellon RF, Cotton RT. Management and prevention of subglottic stenosis in infants and children. In: Bluestone C, Stool S, Alper C, et al, eds. Pediatric otolaryngology. Philadelphia: Saunders; 2002: 1519-1542

2. Wright CD, Graham BB, Grillo HC, Wain JC, Mathisen DJ. Pediatric tracheal surgery. Ann Thorac Surg 2002 ;74: 308-314

3. Cotton RT. Management of subglottic stenosis. Otolaryngologic Clin N Amer 2000; 33: 111-130

4. Yellon RF. Prevention and management of complications of airway surgery in children. Pediatric Anesthesia 2004; 14: 107-111

5. Colt HG, Harrel

High Paying Jobs in the USA – Anesthesiologist

A career in Anesthesiology, begins with choosing the right certifying degree or program from a reputed school which will ensure you get selected for the best jobs in the best hospital facilities. However, which Anesthesiologist Program in the USA, from amongst hundreds will give you excellent education and experience (internship) to be the best anesthetist?

Now that’s one BIG problem to solve.

However fear not. We have compiled a list of the TOP 10 Anesthesiologist Degrees, which is updated frequently, so it always displays the leading anesthetist courses and programs. Some of the leading anesthesiologist schools offering degrees, classes, courses, programs and certifications for specialized Anesthesia like Dental, Neuroanesthesia, Paediatric Anesthesia, Plastic Surgery Anesthesia, CRNA Locum, Eye-Bulbar Anesthesiology, anesthesiologist assistant, etc. are:

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Now that you’ve earned your coveted degree, after much hard work and sweat, you need to begin the search for your dream job as an anesthetist. After all, an anesthesiologist salary ranges between US$ 250,000 to US$ 275,000 per annum, while an Anesthesiologist Assistant average salary is in the range of US$ 100,000. An anesthesiologist nurse salary is around US$ 150,000 per year. You need to apply to/ contact the leading Anesthesiologist Recruitment Agencies in N. America. There are several Anesthesiologist Staffing Agencies in the USA. However, all may not give you optimum results. We have made your work simpler here too.

We have listed the top 10 employment companies that recruit anesthetists, which is also updated very frequently.

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These recruitment agencies are well placed to find the following types of jobs for you:

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There are other methods too that you should not leave out while applying for these jobs. Such as, getting in touch with and applying to, hospital facilities and nursing homes in the area you want a career in; registering on several related job boards and job portals and applying for suitable jobs online. A LinkedIn profile is also a good way to get yourself noticed and searchable by recruiters and headhunters. All of these done together should certainly get you sufficient leads to work on.